Comparative Efficacy of Potassium-Competitive Acid Blockers (P-CABs) Versus Proton Pump Inhibitors (PPIs) in the Management of Erosive Esophagitis: A Systematic Review

This systematic review evaluates the efficacy and safety of vonoprazan and compares it with proton pump inhibitors (PPIs) for the healing and maintenance of erosive esophagitis (EE). A comprehensive search identified five randomized controlled trials published within the last five years, encompassing both short-term healing and long-term maintenance phases. Across studies, vonoprazan consistently demonstrated noninferiority and, in many cases, superiority to lansoprazole, with higher healing rates and lower recurrence, particularly in patients with severe disease (Los Angeles Grade C/D). Long-term data up to five years confirmed sustained efficacy and revealed histopathological changes such as hypergastrinemia and parietal or foveolar hyperplasia with vonoprazan, but no evidence of neoplastic transformation. Additionally, alternate-day dosing showed promising efficacy, suggesting potential cost-effectiveness and mitigation of hypergastrinemia risk. While most evidence originates from Asian populations and some studies had open-label designs, evidence suggests vonoprazan as a potent alternative to PPIs for both induction and maintenance of EE. These results provide clinically meaningful insights for optimizing acid-suppressive therapy and highlight the need for broader, global trials.